Training in laparoscopic renal surgery, in a few weeks of intense exposure.
OBJECTIVE
Laparoscopic renal surgery has only recently become popular in the UK and, still, only a handful of pediatric urologists are offering the laparoscopic approach to their patients; therefore, there are only limited places available for training in this discipline. In this institution, which is a major tertiary referral center for pediatric urology having four consultants, one urologist specializes in laparoscopic renal surgery and about 50 laparoscopic ablative renal surgical procedures are performed annually. The aim of this study was to determine the effectiveness of the training provided, for three trainees, in light of the complexity of the ablative procedures performed.


METHODS
Patients who required laparoscopic ablative renal surgery from June 2003 to May 2004 were identified from the prospectively maintained database and data were analyzed. During this period of 12 months, 49 operations have been performed laparoscopically. There were three trainees, A, B and C, who joined the mentor, at different times, for a continuous period of 6, 12 and 6 weeks, respectively. The training was one to one and, at an appropriate level of expertise, the trainees were allowed to perform operations independently; they continued to do so after returning to their units.


RESULTS
There were 22 males and 27 females, age ranging from 8 months to 16 years (mean 3.6 years). There were 25 nephrectomies, 23 via the prone retroperitoneal (PRP) approach and two via the transperitoneal (TP) approach; the mean time taken was 70 min. There were 12 nephroureterectomies, six via the PRP, three via the TP, and the other three via the lateral retroperitoneal (LRP) approach; the mean time taken was 100 min. There were 10 heminephroureterectomies (six upper pole and four lower pole), six via the PRP, three via the TP and one via the LRP approach; the mean time taken was 160 min. Of two bilateral nephrectomies one was via the PRP and one the TP approach, and the mean time taken was 170 min. The mean time to discharge for nephrectomy was 7 h, and for nephroureterectomy, heminephroureterectomy and bilateral nephrectomy 21, 23 and 43 h, respectively. Trainee A had been in pediatric surgery for 4 years and during a period of 6 weeks he assisted in five operations, but did not get the opportunity to perform independently. Trainee B had been in pediatric surgery for 13 years and during a period of 12 weeks he assisted in nine operations and performed three. Trainee C had been in pediatric surgery for 20 years and during a period of 6 weeks he assisted in five operations and performed one. Since returning to their overseas units, trainee B and trainee C have successfully performed two nephrectomies each.


CONCLUSIONS
Retroperitoneoscopic renal surgery is within the grasp of any experienced urologist or urology trainee. With intensive exposure and one-to-one mentoring, 6-12 weeks would be sufficient to achieve adequate competence and confidence to perform a prone retroperitoneoscopic nephrectomy.
Hennayake
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Department of Paediatric Urology, Royal Manchester Children's Hospital, Hospital Road, Manchester, M27 4HA, UK. supul.hennayake@cmmc.nhs.uk
Jayawardhena
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D
Kumara
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Sakelaris
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G